Monday, July 13, 2015

Diffuse ST Elevation. Diagnosis confirmed with Bedside Echo.

A male in 40's with left sided chest pain since last night with associated shortness of breath. The pain worsens with turning on left side and is best when sitting forward.   He has some cough with sputum.  There was no pericardial friction rub.

Here is the initial ECG:
Diffuse ST elevation, without reciprocal ST depression, mostly in inferior limb leads and lateral precordial leads. This is very typical for pericarditis.

Some ECG factors to consider in diagnosing pericarditis:

1. Diffuse STE, fulfills
2. STE vector towards leads II and V5, fulfills
3. Absence of reciprocal ST depression, fulfills
4. Presence of PR segment depression, fulfills
                 [but is not diagnostic (only about 0.5 mm, which can be normal)]
5. T-waves not prominent, especially ST/T ratio in V6 greater than 0.25, fulfills
6. ST depression in aVR and V1, fulfills
7. Spodick's sign: downsloping TP segment.  This is now known to be neither sensitive nor specific for pericarditis (personal communication on research done by Amal Mattu).  It is absent here.

All these signs are discussed in this recent post.

Clinical factors:

1. Definitely positional
2. Friction rub, not present
3. Pericardial effusion (good specificity, poor sensitivity)

Case progression: 

A bedside echo was done:

Notice the small effusion, seen close to the transducer as a 5 mm echo free stripe.  Furthermore, there was no wall motion abnormality.

Effusion very much increases the probability of pericarditis (though beware hemopericardium in cases of MI with rupture or aortic dissection).

The chest X-ray was negative.

The patient was admitted and ruled out for MI.

Another ECG was recorded 24 hours later:
T-waves are slightly more prominent in affected leads

This is then a classic presentation for pericarditis.  He was treated with NSAIDs and Colchicine.


  1. Something like a slight Spodick sign is present in V4-V6.

  2. Yes - prominent Spodick's in Lead II as well. I don't know of any good data on it, but anecdotally it seems to be more specific when more prominent.

  3. how to differentiate between reinfarction after stent thrombosis (due to medical noncompliance) and post infarction pericarditis? both will cause ST elevation in precordial leads

    1. Recurrent STEMI affects T-waves (larger, taller, wider) more than pericarditis. MI has high T/ST ratio; pericarditis is low ratio. PR depression. There is also more likely to be reciprocal ST shifts, and QRS changes in MI.

    2. But remember: you diagnose pericarditis at your peril. MI is always more likely.


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